A Matter of Life or Death

Imagine you are somehow called upon to save someone’s life and you only have one second to respond. What might you do with that second?

There is an aspect of my work, as a mental health nurse, which involves responding to crises in which there are concerns around people’s safety.

The way I approach a conversation with a client under these circumstances is largely unchanged from how I would at any other time, but the context of it being ‘a crisis’ makes a difference.

I would like to make it clear that what follows is not a description of pure Solution Focused Practice, but my application of Solution Focused Practice being used as appropriately as possible, within the current framework of an eclectic services culture and protocol.

So what constitutes a ‘crisis’?

It could be that I’ve received some prior information that the client has been directed to me because something they’ve said or done has worried someone.

It could be that the client has contacted the service in distress asking to speak with someone as soon as possible.

Or it might be that during a pre-arranged meeting something coming up in conversation has triggered me to start worrying, which might typically be something like an apparent absolute lack of a sense of future, or any significant connections to anyone else, no matter how much I persist in asking about these things.

The difference this makes is that I notice another type of listening becoming more prominent in my awareness, alongside my usual habitual scanning for language which can be used to form questions aligned with the client’s preferred future.

It is a type of listening which is to do primarily with establishing their safety, and recognising a formal, standard ‘risk assessment’ protocol.

The usual questions I would ask at the start of a conversation with a client are along the lines of “what are your best hopes from our talking?” or “what’s been better?” (when the client is returning having been seen before).

Occasionally such questions may seem less congruent in this context, in which case I might instead ask “what’s happened?” or make a statement such as “I understand you’ve asked to talk with someone urgently”, or “I’ve been told you might appreciate some time to talk”.

Having done so, I generally find I receive an account of facing adversity and a confirmation of feeling unable to cope, in which case a statement of acknowledgement; something like “how awful”, “that’s difficult”, or even just “wow” or “phew” or just a long exhalation of breath, followed by a pause, then “so now that you’re here, what are your best hopes from our talking?/ what would you consider to be a good direction to be going in?/ what would you like to happen after our talking?” naturally flows in the conversation, and acts like a kind of ‘reboot’. Another option is to go for something like “so how have you managed to get through?/ find sufficient hope that you can turn this around to ask for help to do so?”

This process can be summarised as:

1. Acknowledge the crisis

2. Pause

3. Acknowledge the hope

4. Establish the client’s choice of direction out of the crisis.

With a more interpretive type of listening central in my awareness, I might ask myself “what did they mean by that?” or “what are they implying they might do after leaving my office?”.

I generally find that just calmly acknowledging these thoughts whilst continuing with the conversation in the usual solution focused way (rather than asking such questions of the client directly) leads to a resolution in which I hear answers which reassure me that they are heading towards safety.

By doing this the conversation can, from the clients perspective, continue to consist of questions and answers which are directly relevant to their hopes, as described in their own words, free from interference from any agenda of mine or the services as far as possible.

Occasionally reassurance is less forthcoming, in which case I might say something like “I’d like to take a slight detour in our conversation here to ask some different questions which are more for the purpose of assessment, because I’m wondering about your safety, then we can return to what we’ve been talking about”.

A core concept in Mental Health Nursing which relates to responding in a crisis is that of ‘de-escalation’, a core component of which is often described in terms of talking with someone in a concise, direct, accepting and respectful manner so as to circumvent conflict and find a mutually acceptable way forwards. A solution focused attitude, tools and skills are very conducive to the application of this concept, so I continue to use them as much as I can while I gather the necessary assessment information.

Having returned from the detour, the natural flow of the conversation leads back into a detailed description of the clients preferred future, which is where their future safety, as a natural aspect of that preferred future, is co-constructed, beginning with the next small step they can take. I believe this is probably the most powerful ‘risk management’ strategy at my disposal, largely because the client’s innate agency (their capacity to act) is recognised and respected.

Incidentally, it stands to reason that this would also apply even when nobody is aware of a ‘crisis’, such as in the case of a client choosing not to disclose the full extent of their plight or ‘open up’ to anyone they are in contact with.

Solution Focused Practice, by its very nature can be seen to build safety.

Given that it’s fair to assume that the client can find a way to do whatever they desire after leaving my office, then having effectively rehearsed a possible future in which they have found a way to be safe and secure again, I believe increases the likelihood of such a future becoming their reality, and sooner than it might have done otherwise.

In very rare cases (approximately 1 in 1000 or so in my experience), effectively I can only be sufficiently reassured that someone is heading towards increasing safety by abandoning the conversation and taking steps for them to be admitted to hospital.

Even under those circumstances, I find opportunities to maintain my solution focused attitude, including an active respect towards the client and belief in their capacity to turn themselves around, which can make a useful difference for them.

This applies even when their liberty is drastically restricted to counter the possibility of them acting on a self-destructive impulse.

Whatever happens, there’s a chance ahead that they’ll recall the choice of action they had previously rehearsed during our conversation and the difference it made in that moment.

Typically, the difference might have been increased hope for a better future, which may encourage them to take them a step closer towards safety, ensuring their immediate survival and providing the opportunity to eventually arrive in that better future.

To recap, when I have concerns about safety, perhaps because of the context, or my instinctive response to what I’m hearing, I notice the emphasis in my listening changes in line with a ‘safety first’ priority in a way which includes more consideration of meaning, and questions evolve from an unusually protective more than empowering stance.

This shift in emphasis is a necessary exception, which reverts as soon as future safety is described reassuringly by the client.

The key to managing this effectively as a professional is second to second adaptability.

Having experienced countless conversations in which safety is a consideration, my conclusion is that we all seem to possess an extraordinarily powerful survival instinct that steers us towards safety even whilst confidence in this happening wavers.

Tragically, it isn’t always powerful enough in itself to save someone’s life, which is where we all come in for each other.

In theory, all suicide is preventable. It can certainly appear that way when individual cases are viewed with the benefit of hindsight.

In practice, in reality, no human endeavour ever has a 100% success rate, and whilst free will exists in our society, people will always find a way to do whatever they most want to do.

Our best bet of reducing instances of people ending their own lives through hopelessness is to therefore collectively do everything we possibly can to amplify the hopes of everyone for a future that is good for every human being in existence, especially those feeling most alone and unable to see a future, so that what everyone most wants to do, in the first instance, is continue to live and to love.

I hope that with greater awareness of the difference it can make to acknowledge, ask about hopes, use the other person’s exact words in conversation, and maintain respect and unshakeable belief in them, more lives might be saved.

This might be through professionals using their honed knowledge, skills, experience and adaptability whenever someone in crisis is fortuitous enough to meet with them, or it might be through anyone, professional or lay person, coming into contact with someone in crisis (knowingly or otherwise), relying on their love and instincts to acknowledge and amplify hope through conversation, then direct people they are still worried about towards professionals.

There are no guarantees. Everyone could be doing everything they possibly can and it still might not be enough to avert tragedy in some cases.

But it might.

I would like to thank Evan George of BRIEF for his answers to my questions on this subject, which supplied a lot of the words I found particularly useful in writing this post.

There are many books and articles covering this subject. One book which I have found particularly inspirational is Heather Fiske’s Hope in Action: Solution-Focused Conversations About Suicide.

Thank you for this helpful article. The process you employ closely resembles the Pathway for Assisting Life Model in Applied Suicide Intervention Skills Training (ASIST). This has been recognised by the U.S. government as en effective evidence based suicide intervention methodology. Risk assessments on the other hands have been found to be largely unhelpful in reflecting actual risk. Do you use risk assessments?

Glad you’ve found it helpful, Nina.
The service I work in currently uses CORE to assess risk, although it’s constantly under review, and DICES has also been considered.
I have heard of ASIST. I will suggest we look into it further. I personally like Signs of Safety.
Above all though, in my opinion, all of these tools are only really a small, relatively inconsequential aspect of what a professional uses when their actions are effective in facilitating life saving change.
I personally believe that it’s my use of the solution focused approach to communication that makes the biggest difference to the direction a client takes.

Chris – Your article was extremely insightful and practical in clearly explaining how you use a solution focused interaction with a distressed or confused client. Many standard assessment processes can upset these clients, who are vulnerable to questions that they then identify as negative. Is it possible to send me a copy of your article that I can share with colleagues and also to refresh my own responses to young people and parents in crisis.

Chris: Your thoughts are not only insightful and clear in describing the modification of a purely SFBT method, but written with such beauty and command of language. Stressing the virtue or emotion of hope is so central to working with people who appear to have lost it can bring forth a new vitality to live and pursue their forgotten dreams. Thanks so much for emphasizing this “hope” dimension which is also so central to SFBT.